- © 2007 Canadian Medical Association or its licensors
Bioethics and armed conflict: Moral dilemmas of medicine and war Michael L. Gross, The MIT Press; 2006 384 pp US$26.00 ISBN 0–262–57226–5
Medical ethics or bioethics is a core component of contemporary Western medical education and practice. Health care providers look to medical ethicists to help navigate health care's complex ethical issues. In Canada and the United States, hospital, medical school and postgraduate training accreditation include evidence of active medical ethics programs. Michael Gross of Haifa University in Israel, in his book Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War, has taken up the daunting challenge of providing an historical, societal, medical, legal and ethical context to the conundrum of bioethics in armed conflict. In an engaging and deliberative fashion, he explores the ethical challenges to contemporary health care providers within and outside the military establishment.
Beyond the relatively protected environment of civilian health care systems, many Western nations have had to contemplate how bioethical principles are used in the face of armed conflict. Some nations are currently engaged in military actions, often in contexts different from traditional wars fought by opposing national armies. The current nontraditional so-called “low-level conflicts,” which include “wars of liberation,” “guerrilla” wars, “terrorist” activities and other unconventional hostile and lethal actions have led to ethical challenges with new dimensions of complexity.
Gross poses a central question: “How does medical ethics help provide an acceptable framework by which nations and their military health care personnel provide care to their own combatants as well as to those of their adversary and to the non-combatants that often get caught up in the conflict with devastating results?” Then he connects the premises and actions to societal values, laws and ethical practices that guide nations in their military and medical decision-making processes. He guides the reader, using an historical perspective, to understand the arguments and counter-arguments about the potential spectrum of the rules of engagement. One nation's approach to medical care within a framework of armed conflict may conflict with that of another nation or what international judicial or medical associations might recommend.
An important section of the book, addresses controversies related to “low-level” conflicts. The contemporary rules for war stem from the major 19th and 20th centuries' wars between nation-states. Many recent armed conflicts such as Vietnam and current conflicts in Iraq, Afghanistan, the Middle East, Sri Lanka and parts of Africa are between armed factions. External nations get involved as members of international bodies like the United Nations or NATO.
It is with less conventional armed conflicts that the roles, responsibilities and the ethical principles of medical care become more contentious. There are often charges that the enemy is not respecting the medical “rights” of the combatants and non-combatants. Participants often refer to various Geneva Conventions to support their arguments, even when those Conventions may not actually pertain to the events in question.
One of the book's most controversial chapters focuses on torture, ill-treatment and interrogation. Gross spans the spectrum of argument from eschewing all medical involvement in such activities, to finding examples of justification using various conceptual approaches to traditional medical ethics. He cites the tension between the arguments for a total prohibition of torture and the potential roles of physicians and its use in compelling situations, “While international conventions make a strenuous effort to safeguard life and self-esteem as fundamental primary goods, the contemporary dilemma of torture and ill-treatment sets the lives of some against the self-esteem of others.”
Gross, with potent arguments and cogent examples, delves into the roles of physicians in armed conflict held by some ethics scholars and how they collide with the recommendations of the World Medical Association within the context of actual “low-level” hostilities.
The last chapter of the book, “The moral dilemmas of medicine and war,” presents a compelling summary of dichotomies that arise from various positions taken about “ethically” acceptable activities. Whatever preconceived and contrary strong opinions one may have about medical ethics in armed conflict, Gross provides an excellent historical, socially sensitive, sound, stimulating and provocative overview of the subject. For readers interested in exploring this complex matter in depth, Gross's book provides an excellent and most readable opportunity.